Cardiovascular Critical Care I
| (d) | Other laboratory values/considerations |
|---|---|
| (1) | Hypercoagulable states (i.e., heparin-induced thrombocytopenia [HIT]) |
| (2) | CBC with differential |
| (3) | Reticulocyte count |
iv.
Treatment
| (a) | Address any evidence of mechanical dysfunction by adjusting speed/flow rates, if possible. |
|---|---|
| (b) | Consider medical optimization of RV function. |
| (c) | If hypovolemic, give volume challenge. Consider alkalinization of urine and optimize |
fluid status (sodium bicarbonate 150 mEq/1000 mL of sterile water) at 0.5–1 mL/kg/hour;
treat to a goal urine pH of greater than 7.5 to avoid additional hemolysis/hemoglobinuria-
related acute kidney injury.
| (d) | Evaluate and optimize anticoagulation strategy. |
|---|---|
| (1) | Ensure therapeutic anticoagulation with heparin or warfarin. |
| (2) | Antithrombotic therapy that is more aggressive may be appropriate. Optimal acute |
antithrombotic strategies, although not yet defined, may include heparin infusion,
glycoprotein IIb/IIIa infusions, parenteral direct thrombin inhibitors, or thrombolytics.
| (3) | Severe hemolysis can potentiate platelet activation – Can consider glycoprotein IIb/ |
|---|
IIIa antagonist therapy (see Table 5), depending on bleeding risks and potential
surgical plan.
| (e) | Reassess long-term antithrombotic strategy. |
|---|---|
| (1) | Consider augmentation of antiplatelet therapy, or increase the INR therapeutic goal |
range.
| (2) | If thought to be related to a concurrent infection, can consider acutely increasing |
|---|
anticoagulation goals until infection control is gained
Infection
LVAD infections are often complex and have been characterized by the International Society
for Heart & Lung Transplantation in the following manner (J Heart Lung Transplant.
2020;39(4):S487):
| (a) | VAD-specific infections |
|---|---|
| (1) | Pump and/or cannula infections |
| (2) | Pocket infections |
| (3) | Percutaneous driveline infections |
| • | Superficial infection |
| • | Deep infection |
| (b) | VAD-related infections |
| (1) | Infective endocarditis |
| (2) | Bloodstream infections that may be VAD related or non–VAD related |
| (3) | Mediastinitis |
| • | Sternal wound infection: Surgical site infection-organ space |
| • | VAD pocket infection (continuous with mediastinum or already situated in the |
mediastinum, depending on the device used)
| • | Other causes of mediastinitis, perforation of the esophagus |
|---|---|
| (4) | Non-VAD infections |
| • | Lower respiratory tract infection |
| • | Cholecystitis |
| • | Clostridium difficile infection |
| • | Urinary tract infection |